Minimally Disruptive Medicine: Thinking differently about nonadherence

In a follow up to Disutility: Finding the balance between benefit and hassle, I present this video from the North American Primary Care Research Group  (NAPCRG) Annual Meeting.

The answer to healthcare is education. Nevermind the other aspects of their life, nevermind that they have multiple diseases, side effects of medications, and not enough time in the day to do all the health 'work' that we give them . Teach patients, yell at patients, scare them into doing what you (the doctor) says. And if they don't take responsibility and do it, then... fire them as your patient!

Or not.

Dr Victor Montori, champion of Minimally Disruptive Medicine, explains a radical new way to think about "nonadherence" and the work that we give our patients to do.

NAPCRG Plenary I: Minimally Disruptive Medicine; Victor Montori, MD


Source: https://www.youtube.com/watch?v=cHSWDMH2rf...

Choosing Wisely Canada: There's an App for that!

It's true! Choosing Wisely Canada now has mobile apps:

They are free and bilingual (French and English) and you'll find them for Google (in the Play store) and for iOS devices (in the Apple store).

The apps are searchable, listing all the recommendations by speciality. There are also links to promotional videos and a library full of PDFs of physician and patient resources.

I have AirPrint enabled on my iPhone and printer, so I could just pull up a handout from the Choosing Wisely App and print it out  - if I don't want to email it - directly for my patients! 

Now there's an example of seamless technology that actually works to help doctors and patients, and will be a part of creating a smooth-operating, high-value health care system.

Source: http://www.choosingwiselycanada.org/news/2...

Does screening for disease save lives in asymptomatic adults? NO

I remember learning in medical school about what a screening test is and the factors necessary to make a 'good' screening test.

The disease in question should:
- constitute a significant public health problem, meaning that it is a common condition with significant morbidity and mortality.
- have a readily available treatment with a potential for cure that increases with early detection.
The test for the disease must:
- be capable of detecting a high proportion of disease in its preclinical state
- be safe to administer
- be reasonable in cost
- lead to demonstrated improved health outcomes
- be widely available, as must the interventions that follow a positive result 

(American Medical Association Council on Scientific Affairs. Commercialized Medical Screening (Report A-03). no longer available online, but cited on Virtual Mentor)

We have obviously lost our way!!

In medical school I was excited about ensuring every patient got ALL THE SCREENING! I never thought I'd struggle to justify a screening test. 

These days, I would be hard-pressed today to confidently name you one "good" screening test. Maybe paps? Maybe colonoscopies? I follow my jurisdiction's guidelines. I discuss the risks and benefits of screening with patients because I'm not certain that what we are doing is definitely "good."

It's hard to summarize it any more clearly than this:

Among currently available screening tests for diseases where death is a common outcome, reductions in disease-specific mortality are uncommon and reductions in all-cause mortality are very rare or non-existent.

A paper in the International Journal of Epidemiology from June 2014 that just came to my attention recently draws this conclusion.

The authors looked at data from 48 Randomized Controlled Trials (RCTs) and 9 meta-analysis on the subject of screening tests (39 of them) for 19 potentially deadly diseases. The studies they included regarded things like mammography for breast cancer, echocardiography for heart disease, PSAs for prostate cancer, and so on.

Some limitations are acknowledged but I also wonder if there is another. For very worthwhile "common sense" things (if these things exist, and I'm not saying they do!) there is little published data. For example, the efficacy of the newborn screening exam or GBS screening in pregnancy don't seem to have been thoroughly studied but are considered to be "law, written in stone" in practice. For the more controversial screening tests, there are more trials published, and so that might weight this meta-analysis towards saying that screening tests on the whole are not useful. I actually think the conclusion the their analysis is appropriate, as the closer we look at other "written in stone" practices, the more we realize we were wrong!

This sentence in the discussion of the article I think sums up the complex nature of the results really well:

There are many potential underlying reasons for the overall poor performance of screening in reducing mortality: the screening test may lack sufficient sensitivity and specificity to capture the disease early in its process; there are no markedly effective treatment options for the disease; treatments are available but the risk-benefit ratio of the whole screening and treatment process is unfavourable; or competing causes of death do not allow us to see a net benefit. Often, these reasons may coexist. Whether screening saves lives can only be reliably proven with RCTs.

See for yourself! Read the full article.

 

CONFERENCE: ISDM/ISEHC2015: Bringing Evidence-Based Practice and Shared Decision-Making Together

What could be better than a conference combining evidence-based practice (EBM) and shared decision making (SDM)!? 

A conference combining EBM and SDM... in Australia!!

That's right, July 19-22, the University of Sydney will be hosting the joint international shared decision-making (ISDM) and International Society for Evidence Based Health Care (ISEHC) conference.

Drs Paul Glasziou (@PaulGlasziou) and Lyndal Trevena (@LyndalTrevena) host, with keynote speeches from Drs Victor Montori (@VMontori), Alexandra Barratt (U of Sydney, organizing committee of Preventing Overdiagnosis), and Sharon Strauss (U of Toronto).

Submit an abstract today! Early bird registration will open soon, and close April 17, 2015. Check out the website and subscribe to their email list so you know as soon as registration opens.

 

Find out about other conferences and events on the subject of Overdiagnosis, the application of evidence and shared decision-making, and Less is More in Medicine.

Canadian Association of Pathologists: Why We Support Choosing Wisely Canada

Dr Christopher Naugler, a pathologist from Alberta (bio), speaks about why the Canadian Association of Pathologists (CAP) support the Choosing Wisely Canada Campaign.

The "Top 5" list of things physicians and patients should discuss, contributed by the CAP can be viewed here.

Having never 'screened' someone for Vitamin D deficiency, I didn't realize how over-ordered the test was. It is a test I have ordered in the North in managing cases of rickets (which still occurs in Nunavut) in conjunction with the advice of a pediatrician or pathologist.

Of course, the Choosing Wisely lists are meant to encourage discussion, and are not blanket statements for all occasions. There are obvious cases where it is wise to order a vitamin D test, and I think the wording of their recommendation captures that :

#1 : Don’t perform population based screening for 25-OH-Vitamin D deficiency.
Vitamin D deficiency is common in many populations, particularly in patients at higher latitudes, during winter months and in those with limited sun exposure. Over the counter Vitamin D supplements and increased summer sun exposure are sufficient for most otherwise healthy patients. Laboratory testing is appropriate in higher risk patients when results will be used to institute more aggressive therapy (e.g., osteoporosis, chronic kidney disease, malabsorption, some infections)

2nd Wave of #ChoosingWisely Canada Recommendations

Choosing Wisely Canada has just released their second wave of recommendations.

If you've been snoozing under a rock, Choosing Wisely is a physician and patient-led campaign to encourage discussions about unnecessary tests and treatments during clinical care.

National specialist societies got together, reviewed the evidence, and created Top 5 (ish) lists relating to things doctors and patients should do less of.

This round, there are recommendations from many groups. Here are a few juicy examples:

From The Canadian Association of Medical Oncologists & Canadian Partnership Against Cancer [full list of 10], eg:

An updated list from CMA’s Forum on General and Family Practice Issues and College of Family Physicians of Canada [full list of 10], eg:

From the Canadian Association of Pathologists [full list of 5], eg:

(See Myths and MSUs for more on this)

These lists are a great start! I was so pleased to see that some of the recommendations really "have teeth." That is to say, the organizations tackled some areas where myths and controversies persist, as change is clearly needed.

I am excited to see the Patient Materials section expand because the tools there will be one of the most important parts of this campaign, which is all about empowering and informing patients.

The CMPA: "Striking the proper balance"

cmpa.JPG

The Canadian Medical Protective Association (CMPA)'s most recent Perspective magazine has, on the cover, an article entitled The right test at the right time: Striking the proper balance (read here).

This is the first time I've seen the organization, which provides medico-legal advice, education, and assistance to its paying physician members, tackle the subject head-on. They have indirectly contributed to this body of knowledge in the past, exploring the concept of 'defensive medicine' and providing references for physicians dealing with the question of providing futile medical care, for example.

For the CMPA to open this article by emphasizing "fiscal prudence" shows that the organization has the freedom to comment in a way that other Canadian organizations find politically uncomfortable. Many others, the Canadian Medical Association (CMA) included, suggest that improved cost will be a result of appropriate care though it is not considered a guiding factor.

The reality is that we all want the same thing: better care for patients, less risk, and a lower cost so that we can sustain high-quality care. Hearing the same message from such a diverse array of medical, political, and citizen groups – in Canada and around the world – breeds hope that we are getting closer to creating the system we envision.

Can this app prevent Overtesting? A look at SnapDx

Sometimes, a new idea is exactly what we need to tackle a longstanding, otherwise insurmountable problem. A little bit of innovation can go a long way.

On the other hand, some new technologies are sexy and flashy but they don't really make a difference for society, or they generate new problems worse than the old.

I'm always on the lookout for creative solutions to the problem of overdiagnosis. Patients, healthcare providers, and society as a whole need to make changes to help create a sustainable, high-quality health care system.

In Doctors create app to help diagnose, treat patients at point of care, Globe and Mail journalist Ivor Tossel describes the aims behind SnapDx.

Dr. Rahul Mehta, an internal medicine resident at the University of Calgary, partnered with colleague Dr. Aravind Ganesh to create the SnapDx app. The app uses evidence-based guidelines to help guide physicians delivering care.

SnapDx Clinical is an efficient bedside assessment tool designed for use by medical trainees and clinicians at the point of care.

We provide the best evidence-based questions and tests to be used as part of your history and physical examination to confidently sort through your differential diagnosis. (from iTunes App description)

The idea is that SnapDx can help aid decisions about diagnosis, giving clinical probabilities that might override the need for ordering laboratory or radiological tests. It does this by emphasizing thorough physical exams, filtering these findings through well-evidenced decision-making tools, and providing probabilities for diagnosis.

Try downloading the SnapDx App (iTunes) yourself, or see the screenshots below for an idea of what it looks like.

I applaud the effort, and I imagine it must have taken a heroic effort to tackle the statistical nightmare behind the scenes, converting everything into a standardized interface.

Despite recognizing this, I must admit I found it a bit cumbersome and hard to understand. Each section has an estimated pre-test probability which is often set to the prevalence rate from a major research study; then, you tick yes/no to various scoring criteria (which are helpfully described in the Info sections). With this, you see the probability for/against a diagnosis. I think. Though it doesn't explicitly say if you should order a test, or which test you should order.

I got a bit bogged down in the details. One big issue I had is that I was not clear on is how to set the positive pre-test probability accurately.

 

For example: when I tried the Pulmonary Embolus (PE) tool, I was thinking of a patient who had recent surgery, recent cancer, immobilization, chest pain, tachypnea, no fever, a normal blood gas, and a normal chest x-ray. There was almost no other diagnosis possible besides a clot in his lungs. Yet because he did not have signs of DVT, hemoptysis, a clotting history, or tachycardia he would not score very high on any of the scales. Of course my pre-test probability for him was high, but I don't know if it was 50% or 99%, and the possible harms of a CT-scan were outweighed by the benefit of ensuring the treatment (high-dose blood thinner; possibly quite harmful) was in fact necessary.

The ambition of Drs Mehta and Ganesh is admirable, and I will keep the app around, looking for future iterations of it. It has the potential to improve clinical accuracy and to decrease ordering of tests that would only confirm what we already know from physical exam. 

Using our detective skills rather than requisitioning a test? It is a great idea.


Simple tool illustrates risks/benefits of prostate cancer screening

Struggling with what to do as far as prostate cancer screening?

The Harding Center for Risk Literacy has some very helpful illustrative "Fact Boxes" that share the evidence behind Digital Rectal Exams (DREs) and Prostate Specific Antigen (PSA) tests.

See the "Risks and benefits of prostate cancer screening" on their site.

Of course, these shared decision-making (SDM) aids only take into account the Cochrane Review, but this is a systematic meta-analysis and so I think quite powerful data.

To see a bit more background, but a similar conclusion, view this review in the Journal of Family Practice. They suggest:

Do not routinely screen all men over the age of 50 for prostate cancer with the prostate-specific antigen (PSA) test. Consider screening men younger than 75 with no cardiovascular or cancer risk factors—the only patient population for whom PSA testing appears to provide even a small benefit.

Family medicine literature seems to be consistent with the above, though our practice lags behind. Many of my urologist colleagues shake their head and insist that we offer screening PSAs, but I'm beginning to feel it just doesn't add up to "good care."


What do you think? Would you get screened? Would you encourage your patients to be screened?

If you are looking for more decision-making aids, check out the Hands On part of the Tools section on this site.

Testing to the Nth degree

When a healthcare provider orders a test, it may be opening the flood gates for further testing. And it's really really really hard to scramble back and undo an unnecessary test after the fact.

When a healthcare provider orders a test, it may be opening the flood gates for further testing. And it's really really really hard to scramble back and undo an unnecessary test after the fact.

Every week I save articles about overtesting, overtreatment, "right care," how to fix out health system, and so on. Today I present:

Four examples of outrageously unnecessary tests

1. An Egregious Example of Ordering Unnecessary Tests
- Patient: 21 year old healthy male for a general annual exam
- Cost: $3682.98 ($13.09 covered by his insurance), confusion, worry
- What happened: The doctor ordered a tonne of lab tests including some I've never even ordered, a stress test (unprecedented in a healthy 21 year old!), etc.
- Comment: The blog writer is appropriately flabbergasted as basically every test ordered was unnecessary; however, he doesn't take it far enough - Routine Physicals themselves are not recommended; annual exams have no scientific value.
 

2. False-Positive Results From a Diagnostic Colonoscopy
- Patient: a middle-aged man with occasional blood in stool
- Cost: unnecessary colonoscopy, exposure to risks, worry/grief about having cancer
- What happened: Although the primary care provider thought the patient had irritable bowel syndrome (IBS) and an ano-rectal source (eg. hemorrhoids) for the occasional blood in the patient's stool, a colonoscopy was ordered. It showed a polyp and the pathology was positive for lymphoma. The patient underwent extensive testing which revealed nothing. The diagnosis of lymphoma was questioned and the patient was diagnosed with hemorrhoids and IBS or food allergy.
- Comment: It's not a bad idea to tell the patient what you are thinking and why you suggest certain things:

"After this experience, the patient stated he would have agreed to an elimination diet, rectal examination, and anoscopy if he had understood what information his physicians could have obtained from these initial tests, prior to pursuing a more invasive option."


3. How the CA-125 became a $50,000 blood test
- Patient: middle-aged female given a CA-125 blood test as "screening" for ovarian cancer
- Cost: $50 000 if you include all the sequelae from that first test
- What happened: The doctor suggested being "safe" and using a test that is not meant for screening as a screening test. When the test was slightly elevated, the doctor suggested further tests. Ultrasounds, CTs, surgeries, etc.
- Comment: I can't say it better than the blog writer when he sums up the costs:

"Five months of mounting worry, loss of several organs, and a simmering distrust of doctors and their tests:  incalculable."


4. Stop hunting for zebras in Texas

- Patient: young man hit in the head with a baseball bat, may be given 2nd CT scan
- Cost: more than necessary
- What happened: A young man who was struck with a baseball bat had a CT scan that showed a Subarachnoid Hemorrhage (SAH). Dr Watson suggested he have another CT (angiogram) scan to see if a brain aneuyrsm was the cause of the bleed. Dr Jha suggested that perhaps the blow to the head was the cause of the bleed in the brain (duhhh!). Dr Watson was "hunting for zebras," i.e. looking for a rare cause to explain the problem rather than the pretty obvious, straightforward one. He thought he had to "rule out" or exclude the rare diagnosis. Dr Jha applied Occam's Razor,  suggesting that while a rare cause was possible it would be far more likely for the simple/obvious cause to be the case.

"Watson’s rationale for fishing for rarities—“can’t be ruled out”—is unfalsifiable. This phrase cannot be disproved. It smashes Bayes’ theorem and Occam’s razor to smithereens. It is kryptonite to clinical acumen . . .
. . . there is wrong: falsely declaring disease in a healthy person—a false positive. And there is (really) wrong: falsely declaring health in a diseased person—a false negative. . . [M]any doctors have chosen being wrong over being really wrong."

- Comment: To "err on the side of caution" seems best at first blush. But being careful has consequences too. In this case, extra radiation (which increases the chance of developing cancer), potential reaction to CT dye (anaphylaxis, kidney failure), the finding of things no one was looking for ("incidentalomas") and further testing required to make sure they aren't bad things, the financial and time cost of the CT scan, etc.

See the article for an excellent narration of the thought process behind this kind of decision-making.